Delivering a personalised, co-ordinated pathway of care for acutely unwell frail individuals
Date: 18 November 2016
The Frailty Team
In 2015, Sanjay Suman, Lead Consultant Geriatrician at Medway NHS Foundation Trust, began a service improvement pathway to improve care for acutely unwell frail individuals admitted to the Trust.
The Acute Frailty Pathway had the overriding principle that patients with acute frailty are seen at the front door by a specialist multidisciplinary team, including a dedicated Consultant Geriatrician, Specialist nurse and a range of other specialists including Physiotherapist, Occupational Therapist, Dietitian and Integrated Discharge Team.
‘Frailty is not a single disease process, so you can’t diagnose it by using something as simple as a laboratory blood test,’ Dr Suman explains. ‘Without a diagnostic tool, it is a challenge for the clinician to accurately and consistently identify a patient that has frailty, and provide them with effective, appropriate treatment.
‘Often, patients with frailty will present with multiple health problems, along with existing long term conditions. What we needed was to develop a simple clinical tool to identify frailty as soon as possible after an acute admission. This would then facilitate a Comprehensive Geriatric Assessment aimed at improving the overall functional capacity of the frail individual in a holistic way.
‘We considered different ways that we could tackle this challenge. One of these was by creating our own tool that would help us to identify frailty. Falls, Reduced mobility, Acute confusion, Incontinence and being prescribed Lots of medications (Polypharmacy) are typical “FRAIL” presentations and this allowed us to include this pneumonic in our clinical tools along with other parameters.
‘Comprehensive Geriatric Assessment is then delivered by an integrated team of professionals – including therapists, nurses and doctors. This has made a big difference in the way we now provide care to the acutely unwell frail patients.
‘This approach enables us to treat the patient much more quickly, and can avoid the need for the patient to be admitted to hospital. Earlier intervention, supported by a treatment and discharge plan, allows more of our patients to return home more quickly. That’s a better result
for the patient and saves vital hospital space.’
The Trust’s approach to treating patients with frailty involves robust partnership working and, importantly, is not age-related. Any patient who presents with frailty presentations listed above will have early access to an integrated team of health professionals, with a named Consultant responsible for their care. This ensures that patients who come here receive better care and timely treatment to improve their overall experience.
Improving care for acutely unwell frail individuals admitted to the Trust